0022-5347 /90/1435-0957$02 00/0 'THE JOURNAL OF UROLOGY
Copyright@ 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETERAL OBSTRUCTION ASSOCIATED WITH PROSTATE CANCER: THE OUTCOME AFTER PERCUTANEOUS NEPHROSTOMY REI K. CHIOU, WEI Y. CHANG
AND
JOHN J. HORAN
From the Department of Urologic Surgery, University of Minnesota Hospital and Clinics and Veterans Administration Medical Center, Minneapolis, Minnesota, and Department of Surgery, Division of Urology, Georgetown University Hospital, Washington, D. C.
ABSTRACT
We retrospectively reviewed the outcome of 37 prostate cancer patients with ureteral obstruction treated by percutaneous nephrostomy. The over-all survival was 57% at 1 year and 29% at 2 years (median survival time 21 months). The 1 and 2-year survival rates of 15 patients with no prior hormonal therapy were 73 and 4 7%, respectively, while those of patients who had previously received hormonal therapy were 48 and 19%, respectively. Median survival times of these groups were 24 months and 12 months, respectively. Of 12 patients who had severe renal failure before percutaneous nephrostomy (serum creatinine greater than or equal to 6.9 mg. per dl.) 9 had an adequate return of renal function (serum creatinine less than 3 mg. per dl.) after drainage and 58% survived more than 1 year (median survival time 22 months). Percutaneous nephrostomy is safe and effective in relieving ureteral obstruction and reasonable survival can be achieved even in patients with renal failure. Percutaneous nephrostomy should be considered strongly in these patients. (J. Ural., 143: 957-959, 1990) Whether to perform urinary diversion in a patient with ureteral obstruction caused by incurable pelvic malignancy often is a difficult decision. Without urinary diversion death of uremia soon follows. However, the outcome after open nephrostomy often is that of short postoperative survival with poor quality of life. 1- 5 Thus, it is common for physicians to advise patients not to undergo diversion. Before the development of modern endourological techniques this often was considered reasonable advice, since surgical nephrostomy and general anesthesia have a significant risk of morbidity and mortality in these debilitated patients. The advent of percutaneous nephrostomy has dramatically decreased the risk of a urinary drainage procedure. 6 - 8 With modern technology we must reexamine the management of these patients. Thus, we reviewed the outcome of prostate cancer patients with ureteral obstruction who were treated with percutaneous nephrostomy at our institution. MATERIALS AND METHODS
The records of 37 consecutive patients who underwent percutaneous nephrostomy for ureteral obstruction associated with prostatic cancer from January 1978 to October 1984 were reviewed. Mean patient age was 73 years (range 58 to 90 years). Of the patients 27 previously were known to have prostate cancer and ureteral obstruction developed 2 months to 12 years after the initial diagnosis. Ten patients presented with ureteral obstruction without a prior diagnosis of prostate cancer. Eleven patients underwent percutaneous nephrostomy while they had only unilateral ureteral obstruction and the remaining 26 underwent nephrostomy after bilateral obstruction had developed. Percutaneous nephrostomy was performed with the patient under local anesthesia. Twelve patients had severe renal failure with a serum creatinine level of greater than or equal to 6.9 mg./dl. (normal 0.8 to 1.4 mg./dl.) before percutaneous nephrostomy (mean serum creatinine was 11.5, with a range of 6.9 to 17.6). A total of 22 patients had received hormonal therapy (diethylstilbestrol or orchiectomy) for the prostate cancer before the development of ureteral obstruction, while 15 patients did not receive such therapy. Two patients were treated with intravenous diethylstilbestrol diphosphate followed by oral diethylstilbestrol in an attempt to relieve ureteral obstrucAccepted for publication November 8, 1989. 957
tion before percutaneous nephrostomy. A total of 4 patients underwent radiation therapy (5,960 to 7,000 rad) for ureteral obstruction. RESULTS
No complications resulted from placement of the percutaneous nephrostomy tube. Kaplan-Meier curves for each subcategory of patients are shown in figures 1 and 2. The over-all survival rates were 57% at 1 year, 29% at 2 years and 14% at 3 years. The median survival was 21 months. As of January 1989 3 patients were still alive at 80, 84 and 116 months, respectively, after percutaneous nephrostomy. The survival of 11 patients with unilateral obstruction at the initial percutaneous procedure was 55% at 1 year, 36% at 2 years and 27% at 3 years (fig. 2). The median survival was 21 months. During followup 4 patients had ureteral obstruction of the contralateral kidney at 7, 19, 46 and 54 months after placement of the percutaneous nephrostomy tube for unilateral obstruction of the ureter. Until death 7 patients had no evidence of contralateral obstruction. The survival of 26 patients with bilateral obstruction at percutaneous nephrostomy was 58% at 1 year, 27% at 2 years and 8% at 3 years, with a median survival of 20 months. There was no significant difference in survival between these patients and those who presented with unilateral obstruction (p = 0.24). Of 12 patients who had severe renal failure before percutaneous nephrostomy 9 had an adequate return of renal function with post-nephrostomy serum creatinine values of less than 3.0 mg./dl. (see table). Two patients had a significant decrease in serum creatinine levels to 3.6 and 5.4 mg./dl., respectively. Renal failure was not relieved in 1 patient who died 6 weeks after percutaneous nephrostomy with a serum creatinine level of 12.0 mg./dl. Survival in this population was 58% at 1 year, 25% at 2 years and 8% at 3 years. One patient was alive at 84 months. Median survival was 22 months. Figure 3 shows the survival of patients who had ureteral obstruction after receiving hormonal therapy compared to that of patients who had no prior hormonal therapy. In 22 patients who had received hormonal therapy (orchiectomy or diethylstilbestrol) before percutaneous nephrostomy the survival was 48% at 1 year, 19% at 2 years and 8% at 3 years. The median postoperative survival was 12 months, with a range of 1.5 to 80 months. A total of 15 patients did not receive hormonal therapy
958
CHIOU, CHANG AND HORAN 100
100 ,._. OVERALL (N=37)
80
-
E
RENAL FAILURE (N= 12)
60
__J
;; 5
O:'. :::i
~
80
~ _J
60
> O::'.
40
:;
40
-
NO HORMONAL THERAPY {n•15) PRIOR HORMONAL THERAPY {n•22)
,-..
=i
(J)
(_f)
20
20
0
0 0
10
20
30
40
50
60
70
FIG. 1. Kaplan-Meier curves representing over-all survival and survival of patients with severe renal failure. 100 .._. BILATERAL (N=26) -
UNILATERAL (N= 11)
~
~ __J
;; 5
O:'. :::i
60 40
(J)
20 0 0
10
20
40
30
50
60
70
MONTHS FIG. 2. Kaplan-Meier curves of patients with unilateral versus bilateral ureteral obstruction.
Outcome of patients who presented with severe renal failure Pt. No. 1
2 3 4 5 6 7 8 9 10 11 12
Serum Creatinine (mg./ di.) -------------~ Before Nephrostomy After Nephrostomy 7.9 10.5 8.7 11.9 6.9 9.7 16.0 17.6 15.3 15.0 9.9 9.1
0.9 3.6 2.4 1.6
2.7 1.7 5.4 12.0 1.4 1.4 1.9 1.1
10
20
30
40
50
60
70
MONTHS
MONTHS
80
0
Survival (mos.) 4
18
24 4
22 22 84* 1.5
28 29 31 6
* Patient was alive as of January 1989.
before percutaneous nephrostomy. Survival in this group was 73% at 1 year, 47% at 2 years and 20% at 3 years, with 2 patients still alive. Median survival was 24 months, with a range of 2 to 116 months. In 2 patients the drainage tubes were removed after complete resolution of obstruction following hormonal therapy. Differences in survival between these 2 groups were not statistically significant (p = 0.15). The administration of intravenous diethylstilbestrol diphosphate and oral diethylstilbestrol in 2 patients did not result in significant improvement of ureter al obstruction within 2 weeks of observation before percutaneous nephrostomy. None of the 4 patients treated with radiation therapy had resolution of ureteral obstruction. DISCUSSION
In the management of patients with ureteral obstruction associated with cancer and when consulting their families the
FIG. 3. Kaplan-Meier curves representing survival of patients with and without prior hormonal therapy.
information about the probable outcome after urinary diversion is of the utmost importance. Most of such information available in the literature consists of that after open nephrostomy. 4 - 6 These studies showed that, although patients with ureteral obstruction associated with prostate cancer appear to fare better than those with other malignancies, the postoperative survivals were still short and patients often spent a significant portion of time in the hospital. Brin and associates reported that 7 prostate cancer patients had an average survival of 12 months, with an average hospital stay of 4 months postoperatively.4 Fallon and Culp reported on 37 prostate cancer patients, of whom 51 % died within 6 months postoperatively (19% died without being discharged from the hospital). 5 Khan and Utz reported that 5 of 7 patients died within 5 months after open nephrostomy. 3 Such unsatisfactory outcome may be partly contributed by the morbidity of open nephrostomy. Sharer and associates reported an operative mortality rate of 29% with open nephrostomy in the treatment of malignant ureteral obstruction.1 Holden and associates noted life-threatening complications in 45% of the cancer patients treated by open nephrostomy.2 Although it is common knowledge that percutaneous nephrostomy is simpler and safer than open nephrostomy, it remains unclear whether patients treated with percutaneous drainage have a better survival rate. 6 - 8 Since the outcome of these patients after open nephrostomy is poor and relatively few reports regarding the outcome after percutaneous nephrostomy are available, many patients and families still are discouraged from electing a urinary drainage procedure and are encouraged to accept a peaceful uremic death even with modern endourological technology. With the safety and simplicity of percutaneous nephrostomy, and the preliminary observation of encouraging outcome the majority of these patients at our institution have elected to undergo percutaneous drainage. Our results showed that 57% of the patients with ureteral obstruction associated with prostate cancer survived longer than 1 year after percutaneous nephrostomy, with a median survival of 21 months after diversion. In contrast to the reported 20 to 45% mortality rate during the same hospitalization after open nephrostomy, only 1 of our patients (3%) died without being discharged from the hospital after percutaneous nephrostomy. Although it is difficult to stratify the cause of death reported in the literature, we believe that such a vast difference in the short-term outcome probably results from decreased morbidity achieved by percutaneous nephrostomy. In view of the poor outcome reported in the literature in the era of surgical nephrostomy, we also wondered whether it was caused by inadequate recovery of renal function after belated attempts at urinary drainage. With such a consideration we performed percutaneous nephrostomy in some patients with unilateral ureteral obstruction. However, we have since noted
URETERAL OBSTRUCTION ASSOCIATED WITH PROSTATE CANCER
that survival of these patients was not better than that of patients who underwent a drainage procedure only after bilateral obstruction had developed (fig. 2). We have since abandoned the practice of draining unilateral ureteral obstruction other than in exceptional situations. However, patients with unilateral ureteral obstruction must be monitored closely. Although all of our patients with mild and moderate azotemia responded well to percutaneous nephrostomy, patients who presented with severe uremia tended to have a prolonged hospital stay and less satisfactory recovery of renal function after drainage. While in some patients the obstruction may remain unilateral throughout the rest of their lives, some of our patients were severely uremic only 2 months after the excretory urogram showed unilateral obstruction. Thus, we believe that it is necessary to monitor the serum creatinine level monthly in these patients to avoid the added morbidity and mortality of severe renal failure. We also recommend renal ultrasonography at 4 to 6-month intervals. Some investigators emphasized that most patients who did reasonably well were those who have not received hormonal therapy. 3 •5 • 9 Recently, Dowling and associates reported that patients who had received prior hormonal therapy did poorly even when percutaneous nephrostomy was used (median survival 4 months) and they discouraged the use of percutaneous drainage in these patients. 10 Although our data indicate that patients without prior hormonal therapy appear to do better, 48% of those with prior hormonal therapy had longer than 1 year of survival after percutaneous nephrostomy. Thus, we believe that percutaneous nephrostomy should not be withheld in this subgroup of patients. Adequate recovery of renal function can be achieved by percutaneous drainage in the majority of azotemic patients. Only 1 of our 12 patients who had renal failure before percutaneous nephrostomy failed to recover enough renal function to sustain life, while the remaining 11 showed significant improvement. Of these patients 9 had return of serum creatinine levels to less than 3 mg./dl. (see table). Others have reported similar findings. Zadra and associates reported on 98 patients with ureteral obstruction caused by a variety of pelvic malignancies and significant improvement in renal function was noted in 93% of the azotemic patients (in 75% the serum creatinine level decreased to a normal range). 6 Sharer and associates reported a return of renal function to normal in 64 % of the azotemic patients after percutaneous nephrostomy. 1 Our finding also is consistent with the literature that one should not rely on the degree of renal failure as a prognostic indicator.2,,,a The outcome of our patients after percutaneous nephrostomy is encouraging. Others have noted less encouraging outcomes even with percutaneous nephrostomy, 6 • 10 which may be a reflection of variation in the natural history of prostate cancer patients. However, we believe that proper management of drainage tubes is necessary to achieve good results. Effective drainage should be ensured and obstruction of the tube should be managed promptly. There are many choices of drainage tubes and urologists often have their own preference. Attempts at retrograde stenting of the ureter often are unsuccessful in
patients with prostate cancer. 6 Thus, we use the percutaneous approach in the majority of these patients. Antegrade ureteral stenting can be performed and patients need not be left with an external appliance. The drawback is that it often is difficult to monitor the patency of the tube and that the subsequent tube change requires more extensive procedures. Use of a transcutaneous nephroureteral stent, such as a Universal* stent, has the advantage of easy access for tube patency evaluation, tube irrigation and tube change. 11 The flank end of the tube can be plugged and the area covered with dressing. Caution must be taken not to have the tube pulled out by accident. With caring and well informed family members, and the assistance of professional home health personnel the problems of tube dislodgement and tube obstruction, and the associated morbidities can be kept to a minimum. In conclusion, ureteral obstruction associated with prostate cancer can be treated effectively with percutaneous drainage. With an appropriate selection of drainage tubes and thoughtful management reasonable survival can be achieved. We believe that by virtue of an approximately 60% chance of adding 1 year or longer to the life span of patients these efforts are worthwhile. Dr. Robert Miller, Radiology Service, Minneapolis Veterans Administration Medical Center, helped to assimilate the patient list. Ms. Linda Pickle, Georgetown University, performed the statistical analysis.
* Cook Urological, Inc., Spencer, Indiana. REFERENCES
1. Sharer, W., Grayhack, J. T. and Graham, J.: Palliative urinary diversion for malignant ureteral obstruction. J. Urol., 120: 162, 1978. 2. Holden, S., McPhee, M. and Grabstald, H.: The rationale of urinary diversion in cancer patients. J. Urol., 121: 19, 1979. 3. Khan, A. U. and Utz, D. C.: Clinical management of carcinoma of prostate associated with bilateral ureteral obstruction. J. Urol., 113: 816, 1975. 4. Brin, E. N., Schiff, M., Jr. and Weiss, R. M.: Palliative urinary diversion for pelvic malignancy. J. Urol., 113: 619, 1975. 5. Fallon, L. 0. and Culp, D. A.: Nephrostomy in cancer patients: to do or not to do? Brit. J. Urol., 52: 237, 1980. 6. Zadra, J. A., Jewett, M. A. S., Keresteci, A. G., Rankin, J. T., St. Louis, E., Grey, R. R. and Pereira, J. J.: Nonoperative urinary diversion for malignant ureteral obstruction. Cancer, 60: 1353, 1987. 7. Ho, P. C., Talner, L. B., Parsons, C. L. and Schmidt, J. D.: Percutaneous nephrostomy: experience in 107 kidneys. Urology, 16: 532, 1980. 8. Culkin, D. J., Wheeler, J. S., Jr., Marsans, R. E., Nam, S. I. and Canning, J. R.: Percutaneous nephrostomy for palliation of metastatic ureteral obstruction. Urology, 30: 229, 1987. 9. Michigan, S. and Catalona, W. J.: Ureteral obstruction from prostatic carcinoma: response to endocrine and radiation therapy. J. Urol., 118: 733, 1977. 10. Dowling, R. A., Carrasco, C. H. and Babaian, R. J.: Percutaneous nephrostomy and adenocarcinoma of the prostate. J. Urol., part 2, 137: 258A, abstract 617, 1987. 11. Badlani, G. H. and Smith, A. D.: Stent for endopyelotomy. Urol. Clin. N. Amer., 15: 445, 1988.
Copyright@ 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETERAL OBSTRUCTION ASSOCIATED WITH PROSTATE CANCER: THE OUTCOME AFTER PERCUTANEOUS NEPHROSTOMY REI K. CHIOU, WEI Y. CHANG
AND
JOHN J. HORAN
From the Department of Urologic Surgery, University of Minnesota Hospital and Clinics and Veterans Administration Medical Center, Minneapolis, Minnesota, and Department of Surgery, Division of Urology, Georgetown University Hospital, Washington, D. C.
ABSTRACT
We retrospectively reviewed the outcome of 37 prostate cancer patients with ureteral obstruction treated by percutaneous nephrostomy. The over-all survival was 57% at 1 year and 29% at 2 years (median survival time 21 months). The 1 and 2-year survival rates of 15 patients with no prior hormonal therapy were 73 and 4 7%, respectively, while those of patients who had previously received hormonal therapy were 48 and 19%, respectively. Median survival times of these groups were 24 months and 12 months, respectively. Of 12 patients who had severe renal failure before percutaneous nephrostomy (serum creatinine greater than or equal to 6.9 mg. per dl.) 9 had an adequate return of renal function (serum creatinine less than 3 mg. per dl.) after drainage and 58% survived more than 1 year (median survival time 22 months). Percutaneous nephrostomy is safe and effective in relieving ureteral obstruction and reasonable survival can be achieved even in patients with renal failure. Percutaneous nephrostomy should be considered strongly in these patients. (J. Ural., 143: 957-959, 1990) Whether to perform urinary diversion in a patient with ureteral obstruction caused by incurable pelvic malignancy often is a difficult decision. Without urinary diversion death of uremia soon follows. However, the outcome after open nephrostomy often is that of short postoperative survival with poor quality of life. 1- 5 Thus, it is common for physicians to advise patients not to undergo diversion. Before the development of modern endourological techniques this often was considered reasonable advice, since surgical nephrostomy and general anesthesia have a significant risk of morbidity and mortality in these debilitated patients. The advent of percutaneous nephrostomy has dramatically decreased the risk of a urinary drainage procedure. 6 - 8 With modern technology we must reexamine the management of these patients. Thus, we reviewed the outcome of prostate cancer patients with ureteral obstruction who were treated with percutaneous nephrostomy at our institution. MATERIALS AND METHODS
The records of 37 consecutive patients who underwent percutaneous nephrostomy for ureteral obstruction associated with prostatic cancer from January 1978 to October 1984 were reviewed. Mean patient age was 73 years (range 58 to 90 years). Of the patients 27 previously were known to have prostate cancer and ureteral obstruction developed 2 months to 12 years after the initial diagnosis. Ten patients presented with ureteral obstruction without a prior diagnosis of prostate cancer. Eleven patients underwent percutaneous nephrostomy while they had only unilateral ureteral obstruction and the remaining 26 underwent nephrostomy after bilateral obstruction had developed. Percutaneous nephrostomy was performed with the patient under local anesthesia. Twelve patients had severe renal failure with a serum creatinine level of greater than or equal to 6.9 mg./dl. (normal 0.8 to 1.4 mg./dl.) before percutaneous nephrostomy (mean serum creatinine was 11.5, with a range of 6.9 to 17.6). A total of 22 patients had received hormonal therapy (diethylstilbestrol or orchiectomy) for the prostate cancer before the development of ureteral obstruction, while 15 patients did not receive such therapy. Two patients were treated with intravenous diethylstilbestrol diphosphate followed by oral diethylstilbestrol in an attempt to relieve ureteral obstrucAccepted for publication November 8, 1989. 957
tion before percutaneous nephrostomy. A total of 4 patients underwent radiation therapy (5,960 to 7,000 rad) for ureteral obstruction. RESULTS
No complications resulted from placement of the percutaneous nephrostomy tube. Kaplan-Meier curves for each subcategory of patients are shown in figures 1 and 2. The over-all survival rates were 57% at 1 year, 29% at 2 years and 14% at 3 years. The median survival was 21 months. As of January 1989 3 patients were still alive at 80, 84 and 116 months, respectively, after percutaneous nephrostomy. The survival of 11 patients with unilateral obstruction at the initial percutaneous procedure was 55% at 1 year, 36% at 2 years and 27% at 3 years (fig. 2). The median survival was 21 months. During followup 4 patients had ureteral obstruction of the contralateral kidney at 7, 19, 46 and 54 months after placement of the percutaneous nephrostomy tube for unilateral obstruction of the ureter. Until death 7 patients had no evidence of contralateral obstruction. The survival of 26 patients with bilateral obstruction at percutaneous nephrostomy was 58% at 1 year, 27% at 2 years and 8% at 3 years, with a median survival of 20 months. There was no significant difference in survival between these patients and those who presented with unilateral obstruction (p = 0.24). Of 12 patients who had severe renal failure before percutaneous nephrostomy 9 had an adequate return of renal function with post-nephrostomy serum creatinine values of less than 3.0 mg./dl. (see table). Two patients had a significant decrease in serum creatinine levels to 3.6 and 5.4 mg./dl., respectively. Renal failure was not relieved in 1 patient who died 6 weeks after percutaneous nephrostomy with a serum creatinine level of 12.0 mg./dl. Survival in this population was 58% at 1 year, 25% at 2 years and 8% at 3 years. One patient was alive at 84 months. Median survival was 22 months. Figure 3 shows the survival of patients who had ureteral obstruction after receiving hormonal therapy compared to that of patients who had no prior hormonal therapy. In 22 patients who had received hormonal therapy (orchiectomy or diethylstilbestrol) before percutaneous nephrostomy the survival was 48% at 1 year, 19% at 2 years and 8% at 3 years. The median postoperative survival was 12 months, with a range of 1.5 to 80 months. A total of 15 patients did not receive hormonal therapy
958
CHIOU, CHANG AND HORAN 100
100 ,._. OVERALL (N=37)
80
-
E
RENAL FAILURE (N= 12)
60
__J
;; 5
O:'. :::i
~
80
~ _J
60
> O::'.
40
:;
40
-
NO HORMONAL THERAPY {n•15) PRIOR HORMONAL THERAPY {n•22)
,-..
=i
(J)
(_f)
20
20
0
0 0
10
20
30
40
50
60
70
FIG. 1. Kaplan-Meier curves representing over-all survival and survival of patients with severe renal failure. 100 .._. BILATERAL (N=26) -
UNILATERAL (N= 11)
~
~ __J
;; 5
O:'. :::i
60 40
(J)
20 0 0
10
20
40
30
50
60
70
MONTHS FIG. 2. Kaplan-Meier curves of patients with unilateral versus bilateral ureteral obstruction.
Outcome of patients who presented with severe renal failure Pt. No. 1
2 3 4 5 6 7 8 9 10 11 12
Serum Creatinine (mg./ di.) -------------~ Before Nephrostomy After Nephrostomy 7.9 10.5 8.7 11.9 6.9 9.7 16.0 17.6 15.3 15.0 9.9 9.1
0.9 3.6 2.4 1.6
2.7 1.7 5.4 12.0 1.4 1.4 1.9 1.1
10
20
30
40
50
60
70
MONTHS
MONTHS
80
0
Survival (mos.) 4
18
24 4
22 22 84* 1.5
28 29 31 6
* Patient was alive as of January 1989.
before percutaneous nephrostomy. Survival in this group was 73% at 1 year, 47% at 2 years and 20% at 3 years, with 2 patients still alive. Median survival was 24 months, with a range of 2 to 116 months. In 2 patients the drainage tubes were removed after complete resolution of obstruction following hormonal therapy. Differences in survival between these 2 groups were not statistically significant (p = 0.15). The administration of intravenous diethylstilbestrol diphosphate and oral diethylstilbestrol in 2 patients did not result in significant improvement of ureter al obstruction within 2 weeks of observation before percutaneous nephrostomy. None of the 4 patients treated with radiation therapy had resolution of ureteral obstruction. DISCUSSION
In the management of patients with ureteral obstruction associated with cancer and when consulting their families the
FIG. 3. Kaplan-Meier curves representing survival of patients with and without prior hormonal therapy.
information about the probable outcome after urinary diversion is of the utmost importance. Most of such information available in the literature consists of that after open nephrostomy. 4 - 6 These studies showed that, although patients with ureteral obstruction associated with prostate cancer appear to fare better than those with other malignancies, the postoperative survivals were still short and patients often spent a significant portion of time in the hospital. Brin and associates reported that 7 prostate cancer patients had an average survival of 12 months, with an average hospital stay of 4 months postoperatively.4 Fallon and Culp reported on 37 prostate cancer patients, of whom 51 % died within 6 months postoperatively (19% died without being discharged from the hospital). 5 Khan and Utz reported that 5 of 7 patients died within 5 months after open nephrostomy. 3 Such unsatisfactory outcome may be partly contributed by the morbidity of open nephrostomy. Sharer and associates reported an operative mortality rate of 29% with open nephrostomy in the treatment of malignant ureteral obstruction.1 Holden and associates noted life-threatening complications in 45% of the cancer patients treated by open nephrostomy.2 Although it is common knowledge that percutaneous nephrostomy is simpler and safer than open nephrostomy, it remains unclear whether patients treated with percutaneous drainage have a better survival rate. 6 - 8 Since the outcome of these patients after open nephrostomy is poor and relatively few reports regarding the outcome after percutaneous nephrostomy are available, many patients and families still are discouraged from electing a urinary drainage procedure and are encouraged to accept a peaceful uremic death even with modern endourological technology. With the safety and simplicity of percutaneous nephrostomy, and the preliminary observation of encouraging outcome the majority of these patients at our institution have elected to undergo percutaneous drainage. Our results showed that 57% of the patients with ureteral obstruction associated with prostate cancer survived longer than 1 year after percutaneous nephrostomy, with a median survival of 21 months after diversion. In contrast to the reported 20 to 45% mortality rate during the same hospitalization after open nephrostomy, only 1 of our patients (3%) died without being discharged from the hospital after percutaneous nephrostomy. Although it is difficult to stratify the cause of death reported in the literature, we believe that such a vast difference in the short-term outcome probably results from decreased morbidity achieved by percutaneous nephrostomy. In view of the poor outcome reported in the literature in the era of surgical nephrostomy, we also wondered whether it was caused by inadequate recovery of renal function after belated attempts at urinary drainage. With such a consideration we performed percutaneous nephrostomy in some patients with unilateral ureteral obstruction. However, we have since noted
URETERAL OBSTRUCTION ASSOCIATED WITH PROSTATE CANCER
that survival of these patients was not better than that of patients who underwent a drainage procedure only after bilateral obstruction had developed (fig. 2). We have since abandoned the practice of draining unilateral ureteral obstruction other than in exceptional situations. However, patients with unilateral ureteral obstruction must be monitored closely. Although all of our patients with mild and moderate azotemia responded well to percutaneous nephrostomy, patients who presented with severe uremia tended to have a prolonged hospital stay and less satisfactory recovery of renal function after drainage. While in some patients the obstruction may remain unilateral throughout the rest of their lives, some of our patients were severely uremic only 2 months after the excretory urogram showed unilateral obstruction. Thus, we believe that it is necessary to monitor the serum creatinine level monthly in these patients to avoid the added morbidity and mortality of severe renal failure. We also recommend renal ultrasonography at 4 to 6-month intervals. Some investigators emphasized that most patients who did reasonably well were those who have not received hormonal therapy. 3 •5 • 9 Recently, Dowling and associates reported that patients who had received prior hormonal therapy did poorly even when percutaneous nephrostomy was used (median survival 4 months) and they discouraged the use of percutaneous drainage in these patients. 10 Although our data indicate that patients without prior hormonal therapy appear to do better, 48% of those with prior hormonal therapy had longer than 1 year of survival after percutaneous nephrostomy. Thus, we believe that percutaneous nephrostomy should not be withheld in this subgroup of patients. Adequate recovery of renal function can be achieved by percutaneous drainage in the majority of azotemic patients. Only 1 of our 12 patients who had renal failure before percutaneous nephrostomy failed to recover enough renal function to sustain life, while the remaining 11 showed significant improvement. Of these patients 9 had return of serum creatinine levels to less than 3 mg./dl. (see table). Others have reported similar findings. Zadra and associates reported on 98 patients with ureteral obstruction caused by a variety of pelvic malignancies and significant improvement in renal function was noted in 93% of the azotemic patients (in 75% the serum creatinine level decreased to a normal range). 6 Sharer and associates reported a return of renal function to normal in 64 % of the azotemic patients after percutaneous nephrostomy. 1 Our finding also is consistent with the literature that one should not rely on the degree of renal failure as a prognostic indicator.2,,,a The outcome of our patients after percutaneous nephrostomy is encouraging. Others have noted less encouraging outcomes even with percutaneous nephrostomy, 6 • 10 which may be a reflection of variation in the natural history of prostate cancer patients. However, we believe that proper management of drainage tubes is necessary to achieve good results. Effective drainage should be ensured and obstruction of the tube should be managed promptly. There are many choices of drainage tubes and urologists often have their own preference. Attempts at retrograde stenting of the ureter often are unsuccessful in
patients with prostate cancer. 6 Thus, we use the percutaneous approach in the majority of these patients. Antegrade ureteral stenting can be performed and patients need not be left with an external appliance. The drawback is that it often is difficult to monitor the patency of the tube and that the subsequent tube change requires more extensive procedures. Use of a transcutaneous nephroureteral stent, such as a Universal* stent, has the advantage of easy access for tube patency evaluation, tube irrigation and tube change. 11 The flank end of the tube can be plugged and the area covered with dressing. Caution must be taken not to have the tube pulled out by accident. With caring and well informed family members, and the assistance of professional home health personnel the problems of tube dislodgement and tube obstruction, and the associated morbidities can be kept to a minimum. In conclusion, ureteral obstruction associated with prostate cancer can be treated effectively with percutaneous drainage. With an appropriate selection of drainage tubes and thoughtful management reasonable survival can be achieved. We believe that by virtue of an approximately 60% chance of adding 1 year or longer to the life span of patients these efforts are worthwhile. Dr. Robert Miller, Radiology Service, Minneapolis Veterans Administration Medical Center, helped to assimilate the patient list. Ms. Linda Pickle, Georgetown University, performed the statistical analysis.
* Cook Urological, Inc., Spencer, Indiana. REFERENCES
1. Sharer, W., Grayhack, J. T. and Graham, J.: Palliative urinary diversion for malignant ureteral obstruction. J. Urol., 120: 162, 1978. 2. Holden, S., McPhee, M. and Grabstald, H.: The rationale of urinary diversion in cancer patients. J. Urol., 121: 19, 1979. 3. Khan, A. U. and Utz, D. C.: Clinical management of carcinoma of prostate associated with bilateral ureteral obstruction. J. Urol., 113: 816, 1975. 4. Brin, E. N., Schiff, M., Jr. and Weiss, R. M.: Palliative urinary diversion for pelvic malignancy. J. Urol., 113: 619, 1975. 5. Fallon, L. 0. and Culp, D. A.: Nephrostomy in cancer patients: to do or not to do? Brit. J. Urol., 52: 237, 1980. 6. Zadra, J. A., Jewett, M. A. S., Keresteci, A. G., Rankin, J. T., St. Louis, E., Grey, R. R. and Pereira, J. J.: Nonoperative urinary diversion for malignant ureteral obstruction. Cancer, 60: 1353, 1987. 7. Ho, P. C., Talner, L. B., Parsons, C. L. and Schmidt, J. D.: Percutaneous nephrostomy: experience in 107 kidneys. Urology, 16: 532, 1980. 8. Culkin, D. J., Wheeler, J. S., Jr., Marsans, R. E., Nam, S. I. and Canning, J. R.: Percutaneous nephrostomy for palliation of metastatic ureteral obstruction. Urology, 30: 229, 1987. 9. Michigan, S. and Catalona, W. J.: Ureteral obstruction from prostatic carcinoma: response to endocrine and radiation therapy. J. Urol., 118: 733, 1977. 10. Dowling, R. A., Carrasco, C. H. and Babaian, R. J.: Percutaneous nephrostomy and adenocarcinoma of the prostate. J. Urol., part 2, 137: 258A, abstract 617, 1987. 11. Badlani, G. H. and Smith, A. D.: Stent for endopyelotomy. Urol. Clin. N. Amer., 15: 445, 1988.
